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| By

Ricky Sayal, DO

The area that surrounds the mouth, also known as the perioral area, is the first thing patients notice about themselves when it comes to aging—and for good reason! There are many factors involved in this aging transformation: resorption of bone, aging skin, gravity, and fat degeneration. 

The bony resorption of the mandible (jaw) causes the face to flatten, and in combination with gravity pulling down on the soft tissue it creates excess skin which we call “jowls.” The corners of the mouth become downturned with time. The fat that was once held high on the cheeks migrates down to the mouth and manifests itself as nasolabial folds and marionette lines at the corners of the lips. The dermis (skin) thins and the elastin keeping the skin tight becomes scarce. Fine vertical lines begin to appear around the mouth. The good news is, there are effective ways to prevent this from happening and also combat the signs of aging around the mouth that appear as we get older.

Because the aging process of the mouth area is based on a variety of factors, a tailored plan for your rejuvenation must be customized. Every patient’s aging is different. As facial plastic surgeons, we have learned and developed state-of-the-art techniques to help recreate a youthful appearance. Neuromodulators, such as Botox, soften the dynamic, deep vertical lines and the downturned corners of the mouth by relaxing the muscles involved. Fillers soften static lines and add back the volume that is lost due to aging. They are versatile and can be utilized in different regions of the face to soften the static lines along the nasolabial folds (also known as “smile lines”) and marionette lines or uplift the downturned corners of the mouth. The skin quality and fine lines can be addressed with laser skin resurfacing. This popular cosmetic treatment improves the tone and texture while stimulating collagen remodeling, which ultimately tightens the skin.

What Can I Do At Home?

The first thing you should do is protect yourself from sun damaged skin. Ultraviolet (UV) radiation damages the structural collagen of the skin and blood vessels. Apply a water-resistant broad-spectrum sunscreen that has a sun protection factor (SPF) of 30 or above or a minimum 12% zinc oxide that shields you from both UV-A and UV-B rays. Don’t forget about protecting your lips! I recommend using a product geared specifically for the lips with at least a SPF 20 or above. Wearing SPF not only prevents skin cancer and wrinkling, but it also reduces future pigmentation that can occur with sun damage.

Next, it can be beneficial to start a proper skin care regimen approximately four weeks prior to some nonsurgical rejuvenation treatments, like laser skin resurfacing. Products such as retinol increase fibroblasts that stimulate collagen production. Vitamin C and hydroquinone can be used by themselves or in combination. They are very useful to help with the texture of the skin and to remove unwanted pigmentation. Working with someone skilled in skin rejuvenation, like a medical aesthetician, will enhance your final result.

What Can I Expect During the Consultation?

During the consultation with my patients, I step back and look at the big picture. I make sure to consider all the factors of why the mouth changes with age: the patient’s skin type, aging features, and past medical history. All of these play a role in my decision-making process. I consider the patient’s availability and the downtime they might need after a procedure. It is important to gain a sense of the patient’s daily routine and occupation before formulating a treatment plan.

I like to evaluate the patient in the upright position. I start from the outside of the face and move toward the center: big lines first and then small lines. I use the following method for evaluation: 

  • First, I examine the nasolabial folds, the big lines on the perimeter of the mouth area. They outline the region that I wish to treat and give me perspective of the mouth in relation to the face. 
  • Next, I look at the marionette area three-dimensionally. I assess it from the front, side, and then at an oblique angle. I treat this region with respect; it isn’t just a straight line but rather a topographic region with distinguished features. 
  • The corner of the mouth is next. Due to the aging process, the corner of the mouth can develop a slanted appearance, which conveys a sad emotion even when a patient feels happy. 
  • I assess the skin just outside the lip region. We tend to develop vertical lines from the muscle responsible for mouth contraction. They are often accentuated in smokers who use this muscle more than others. 
  • Finally, the lips are assessed. I note the structure, volume, and ratio in relation to the rest of the face. 

Being consistent and having a rhythm during the consultation ensures that I don’t miss an important detail for formulating a treatment plan. 

Get the most out of your consultation. Come prepared with this comprehensive checklist to help you ask all the right questions. 

Which Treatments Work On the Mouth Muscles?

There are three muscles that can be relaxed with Botox or another neuromodulator: orbicularis oris (OO), depressor anguli oris (DAO), and levator labaii superioris alaque nasi (LLSA). 

Known as the “kissing muscle,” the OO is the circular muscle responsible for vertical lines and wrinkles. This strong muscle contains fibers coming in from multiple angles. Using Botox on the OO can reduce some of these wrinkles. For example, you may have heard of the “lip flip” procedure which relaxes this muscle to evert the upper lip. This gives it more flare and a more youthful appearance. To perform this procedure, a small amount of neuromodulator is placed along the upper lip border. The placement must be very superficial, just underneath the skin. Experienced injectors ensure that the amount placed is symmetric.

The DAO muscle contributes to the downturned corners of the mouth. When providing treatment, I ask the patient to frown. This helps me identify this muscle as I precisely place the product approximately 1.5 cm lateral to a line drawn directly down from the corner of the mouth. 

Some patients experience excess gingival show when smiling, known as a “gummy smile.” This can be for a number of reasons: teeth that improperly erupted, a short upper lip, a hyperactive upper lip that lifts too high when smiling, or gingival hypertrophy. To counteract this, the LLSA muscle is relaxed with a small amount of neuromodulator placed deep, where the muscle attaches to the bone. This relaxes the upper lip to show a desired, beautiful smile.

What Role Do Fillers Play?

Fillers are a versatile product in the perioral region to add volume and hide lines. Prior to addressing this issue, the provider should have a mastery of the surrounding facial anatomy because there are many facial blood vessels. The facial artery branches into the angular artery and the superior and inferior labial arteries. There is a high risk for bruising, swelling, and hematoma formation. Inadequate knowledge and experience in this region can lead to unwanted complications. To avoid this, I always keep the product moving and place it slowly, in very small increments.

Starting from the outside with the nasolabial fold, a sturdy filler can be placed deep on the maxillary (cheek) bone to create a lifting effect. One can inject the nasolabial itself, but the action is really getting the cheek region to lift which, in turns, softens the nasolabial fold. Also, the product is placed directly over the bone on the cheek, which is a safe area.

After lifting the cheek, if the nasolabial folds are still prominent, I address those directly. I place the filler along the nasolabial fold. It is important to note that the product should not completely efface the nasolabial fold; even babies have a nasolabial fold. I then mold it into the desired position. I prefer using a thin filler in this region because this is a more superficial injection than the cheek product placement. One should be cautious by injecting slowly and carefully, because the angular artery runs in this region.

I address the marionette lines next. I visualize this area like a triangle extending from the corner of the mouth to the prejowl sulcus (the outside of the chin area). If the patient demonstrates aging and volume loss, I place the filler in the region three-dimensionally, treating the space rather than just the line. This helps provide structural support for the lower lip and decreases the shadowing effect to this site. 

The type of filler used in this region is entirely dependent on the depth of the injection. If the purpose is to lift the volume-depleted region, I inject deep and use a thick filler. Otherwise, a thin filler is appropriate for a more superficial treatment, just under the skin. Some patients require layering of a few different types of filler. The corners of the mouth are often addressed at this point, which provides support to lift the downturned corners into a more youthful, refreshed position.

The vertical fine lines above the lips are treated with a thin filler, placed very superficially. It is important to not over-inject filler in this region; over-filling here can provide an unsatisfactory aesthetic result. As we age, the lips become thin, flatten out, and lose their volume. Previous studies indicate the “golden ratio” of the upper lip to lower lip is 1:1.6. I am always interested in what the patient is trying to achieve and am curious of their own perception of their proportions. If the patient would like general enhancement, I use a medium-sized filler. If the patient wants large, voluptuous lips, I use a product that pulls in more water. Most patients request a natural look, one that produces defined lips and is not “duck-like.”

Which Laser Skin Treatment Is Right For Me?

Laser skin resurfacing works very well for rejuvenating the skin and stimulating collagen production. There are different modalities of treatment that work harmoniously to provide the best outcome. 

Laser Skin Resurfacing Around Mouth_Before and After_Clevens

Some patients are good candidates for nonablative lasers such as the Erbium laser. This laser stimulates collagen formation in the deeper dermal tissue without removing the outer layer of skin. The advantage in using a non-ablative laser is that there is minimal downtime; one can generally resume normal activities after 24-48 hours. Also, this laser can be used on all ranges of skin types.

Ablative CO2 laser skin resurfacing works very well in the perioral region. I always recommend ablative CO2 treatment for qualified patients because it provides the most improvement. This type of laser works by creating microscopic columns of thermal damage surrounded by columns of healthy skin tissue. This allows for rapid recovery with the optimal result. Although the downtime is 5-7 days, the cosmetic result is excellent. 

The best way to determine an ideal laser treatment for your skin type is to work with an experienced facial plastic surgeon. Laser skin resurfacing is a powerful tool and you want to make your decision based on the provider’s training and experience, not cost.

What Are You Waiting For?

Your mouth changes with age and the perioral region undergoes many stages as time passes. Your provider should correctly identify the aging features pertinent to your face and customize a tailored plan for you. Most of the time, this requires the use of multiple modalities for optimal results. If you’re ready to speak with a specialist, request your consultation. It is important that you choose someone with extensive experience who shares the same vision as yours!


Get the most out of your consultation. Come prepared with this comprehensive checklist to help you ask all the right questions. 

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